ESTACADA VOLUNTEER MEMBERSHIP APPLICATION

ESTACADA RURAL FIRE DISTRICT 69

Proudly serving Estacada and surrounding communities
VOLUNTEER MEMBERSHIP APPLICATION
Name *

First Name Last Name
Date *

Month Day Year
Date
Position Applied For: (Mark each that apply)

Volunteer In District Firefighter These volunteers perform suppression firefighting, emergency medical care, fire prevention duties, and other incident response services from our stations in the City of Estacada and George community. This program requires residency within the Fire District boundaries. This program requires approximately 200 hours of initial training over a six-month period. The time commitment for this position is about 16-20 hours each month. Our goal is to maintain 40 In District Firefighters. Volunteer Out of District Firefighter These volunteers perform suppression firefighting, emergency medical care, fire prevention duties, and other incident response services from our stations in the City of Estacada and George community. This program is for volunteers that live outside of the Fire District boundaries and requires approximately 200 hours of initial training over a six-month period. The time commitment for this position is about 26-30 hours each month. Our goal is to maintain 10 Out of District Firefighters. Volunteer In District EMS Responder In District volunteers are members who are physician assistants, registered nurses, EMTs or paramedics that desire to respond on only medical calls. Medical incidents make up about 70% of our calls for service. The time commitment for this position is about 12 14 hours each month. Our goal is to maintain 10 EMS Responders. Volunteer Out of District EMS Responder Out of District volunteers are members who are physician assistants, registered nurses, EMTs or paramedics that desire to respond on only medical calls. Medical incidents make up about 70% of our calls for service. The time commitment for this position is about 20-24 hours each month. Our goal is to maintain 10 EMS Responders. Volunteer Water Tender Operator The Water Tender Operators provide a specialized service of responding and operating water tender apparatus. This program requires residency within the Fire District boundaries. These volunteers respond to all fires and incidents within and outside of the Fire District in areas where hydrants are not available. This specialized service category is for volunteers that do not desire to maintain the higher training, annual compliance, certification and medical requirements that is required of Volunteer Firefighters. The time commitment for this position is about 6-10 hours per month. Our goal is to maintain 5 Water Tender Operators. Volunteer Fire Corps Member Fire Corps volunteers provide support operations on emergency scenes by providing incident rehabilitation services. Additionally, they provide first aid, fire prevention services, public relations and other specialized emergency scene support functions. Our Fire Corps group responds to all working fires as well as other incidents. The time commitment is about 6-10 hours per month. Our goal is to maintain 15 Fire Corps members.
ESTACADA RURAL FIRE DISTRICT 69 VOLUNTEER MEMBERSHIP APPLICATION

P.O. BOX 1385 ESTACADA, OREGON 97023
Estacada Rural Fire District No. 69 makes its volunteer recruitment decisions without regard to race, color, sex, national origin, religion, marital status, age, prior industrial injury, or mental or physical handicaps unrelated to job performance.

It is the District’s policy to comply with the provisions of the Immigration Reform and Control Act of 1986 and to recruit only authorized volunteers. If you are hired, you will be asked to provide verification of your eligibility. The types of verification required may change from time to time as federal regulations are promulgated or amended. Your volunteer services will not be continued if you are unable to or are unwilling to provide the verification requested by the District.

Estacada Rural Fire District No. 69’s pre-entry and physical agility examination has been developed due to the complexity and changes of the Fire Service as we know it today. In addition, there are many mandated certification and skill levels that the Fire District must assure that all members attain. Many of these mandates or standards are established by Federal and State laws, Accident Prevention Division, OSHA, National Fire Protection Association, and the Oregon State Fire Marshal's Office.

This pre-entry test and physical agility test will assist the Fire District in assessing your success in the numerous certification and task levels you will be expected to achieve as a Volunteer member of the Estacada Rural Fire District.

This application will be considered only for the specific job applied for. If you desire to be considered for a position at a future time, you must file a new application.
Name

First Name Last Name
Date

Month Day Year
Date
Social Security No.
Telephone
Email Address
example@example.com
Address

Address

Street Address Line 2

City State

Zip Code
Driver’s License No.
State Issued
License Class
Are you over 18 years of age?

Yes, No
Have you ever worked or volunteered for the District before?

Yes, No
If Yes, list the beginning and ending dates worked AND positions held:
Have you ever worked or volunteered for another Fire or EMS agency?

Yes, No
If Yes, list the beginning and ending dates worked AND positions held:
Do you have any relatives, either by blood or marriage, who currently work for the District, volunteer for the District, or who are members of the board of directors of the District?

Yes, No
If yes, give their name(s):
Please describe any education, training, qualifications, hobbies, or skills that you think are relevant to the position for which you are applying.
Motivation
In an effort to assist us in understanding your motivation to be a volunteer for Estacada Rural Fire District No. 69, please answer the following questions: (Check all that apply)
How did you hear about us?

News Paper Ad Facebook Twitter Contact with a member Fire Prevention Paper Sign or Banner Interest Card Brochure Website Other
Who Referred You:
Tell us why you would like to be a volunteer?
Previous Work Experience
Please list all employment and any periods of unemployment for the last 10 years, beginning with the most recent employment.
May we make inquiries of your current employer?

Yes No
Company Name
Telephone No.
Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Immediate Supervisor’s Name
First Date Employed

Month Day Year
Date
Last date employed

Month Day Year
Date
Position(s) Held
Job Responsibilities, Equipment Operated
Job Responsibilities, Equipment Operated
Reason for Leaving
Company Name
Telephone No.
Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Immediate Supervisor’s Name
First Date Employed

Month Day Year
Date
Last date employed

Month Day Year
Date
Position(s) Held
Job Responsibilities, Equipment Operated
Reason for Leaving
Company Name
Telephone No.
Company Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Immediate Supervisor’s Name
First Date Employed

Month Day Year
Date
Last date employed

Month Day Year
Date
Position(s) Held
Job Responsibilities, Equipment Operated
Reason for Leaving
Background Investigation

(Required by OAR 259-008-0015)
Criminal History and Arrests
Please list any criminal convictions including traffic infractions. Include nature of offense leading to the conviction(s), date of conviction(s), and sentence(s) imposed. You will not be automatically excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the totality of the circumstances, such as: the nature of the crime, the timelines of the conviction, and the type of work involved.
Do you currently use illegal drugs?

Yes No
If yes, what illegal drugs do you currently use?
Have you ever used illegal drugs?

Yes No
If so, when was the last time you used illegal drugs?
Education Verification
High School Attended
High School Diploma?

Yes No
G.E.D?

Yes No

List Colleges or Trade Schools attended following high school:

SCHOOL

FROM/TO

FIELD OF STUDY

CREDIT

DEGREE

Military History Verification
Have you served in the Military?

Yes No
If so, which branch?
References
List three persons other than relatives or previous employers who have known you longer than one year. Do not include any person who lives in your household.

Personal References - Please List 3

Name

Address

Phone

Occupation

Reference 1

Reference 2

Reference 3

Professional References - Please List 3

Name

Address

Phone

Occupation

Reference 1

Reference 2

Reference 3

Do you use Social Media?

Yes No
If so, please list the web addresses to your social media pages below:
Volunteer Declaration
I, your name here by signing this document do declare that if I am selected as a volunteer member of the Estacada Rural Fire District No. 69 I do so as a service to the community and do not expect compensation for service rendered.
Authorization
In submitting this application, I authorize the investigation of all statements contained in it, and it is understood and agreed that any misrepresentation by me in this application (or attached resume, if any) may result in cancellation of the application and/or separation from the District’s service. I affirm that all information in this application is truthful. I agree that I will undergo a physical examination at the District’s expense if requested by the District, and that a physical examination may include a drug screen. I agree that if I do not maintain active volunteer membership for the first year, I may be responsible for any costs associated with testing, physical examinations, background checks, training, and administrative fees.

In consideration of any volunteer position, I agree to conform to the rules and regulations of the District. My volunteer position can be terminated, with or without cause, and with or without notice, at any time, at the option of either the District or myself. I understand that no representative of the District except the fire chief or the board of directors has the authority to enter into any agreement for any specified time or to make any agreement contrary to the foregoing. I certify I have read all of this application and the information I have provided above is true and correct.
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

ESTACADA RURAL FIRE DISTRICT 69

VOLUNTEER MEMBERSHIP APPLICATION

ESTACADA RURAL FIRE DISTRICT 69 VOLUNTEER MEMBERSHIP APPLICATION

Motivation

Previous Work Experience

Background Investigation

Criminal History and Arrests

Education Verification

Military History Verification

References

Volunteer Declaration

Authorization